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Do we have a definition of an unnecessary cesarean section? -Dr. Mario Sebastiani. Asociación Do we have a definition of an unnecessary cesarean section? -Dr. Mario Sebastiani. Asociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina

Published rates ü W. H. O. : 1 • • • 15 % Maximum Published rates ü W. H. O. : 1 • • • 15 % Maximum desirable rate of cesarean section No benefit for mother and the fetus for medical reasons 1 World Health Organisation. Appropriate technology for birth. Lancet 1985; 436 7. Unnecesary C- section ?

Outcome based study Sweden: 1 ü 59 hospitals ü 1988 1992 • Perinatal mortality Outcome based study Sweden: 1 ü 59 hospitals ü 1988 1992 • Perinatal mortality • Rate of asphixia No benefit Minimum cesarean section rate is optimal 1 Eckerlund I, et al. , Int J Technol Asses Health Care 1999; 15: 123 35 Unnecesary C- section ?

Outcome based study England 1 ü 17 maternity units (one health region) ü 1988 Outcome based study England 1 ü 17 maternity units (one health region) ü 1988 ü 36. 727 singleton pregnancies • CS rates should be 10 - 12 % • More intervensionist approach in low birth weight infants 1 Joffe Unnecesary C- section ? M, et al. , J Epidemiol Community Health 1994; 48: 406 11

Healthy People 2000 1 ü Department of Health and Human Services ü 15 % Healthy People 2000 1 ü Department of Health and Human Services ü 15 % by the year 2000 “. . the advantages of a safe vaginal delivery over a cesarean delivery are clear: a vaginal delivery is associated with lower maternal and neonatal morbilidity and it costs less. . . ” 1 Unnecesary C- section ? Healthy People 2000; DHHS publication Nº. (PHS) 91 50212.

Latin America Latin America

Grafic I: Incidence of ceasarean secton in Latin American W. H. O. Unnecesary C- Grafic I: Incidence of ceasarean secton in Latin American W. H. O. Unnecesary C- section ? Belizán JM, et al, BMJ 1999; 319: 1397 402

Grafic I: Incidence of ceasarean secton in Latin American W. H. O. Unnecesary C- Grafic I: Incidence of ceasarean secton in Latin American W. H. O. Unnecesary C- section ? Belizán JM, et al, BMJ 1999; 319: 1397 402

“Rates and implications of caesarean sections in Latin America: ecological study” Belizán JM, et “Rates and implications of caesarean sections in Latin America: ecological study” Belizán JM, et al, BMJ 1999; 319: 1397 402 ü 12 of 19 Latin American countries ü 81% of the deliveries ü C-S rates above 15% (16, 8% - 40%) ü Better socioeconomic conditions = higher C-S rates ü Over 850. 000 unnecesary c-sections are performed each year in LA Unnecesary C- section ?

Why has the rate of cesarean delivery climbed so dramatically in the past 25 Why has the rate of cesarean delivery climbed so dramatically in the past 25 years? 1. Lower tolerance for taking risks 2. Fear of malpractice litigation 3. Increased use of epidural anesthesia ? 4. Increased use of electronic fetal monitoring 5. The convenience of physicians Unnecesary C- section ? Sachs BP et al. , NEJM 1999; 340: 54 – 57

Difficulties for the analysis ü Which is the optimun cesarean rate? ü Many stategies Difficulties for the analysis ü Which is the optimun cesarean rate? ü Many stategies to reduce the rates Unnecesary C- section ?

Difficulties for the analysis ü Which is the optimun cesarean rate? ü Many stategies Difficulties for the analysis ü Which is the optimun cesarean rate? ü Many stategies to reduce the rates Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure Medical and non medical reason Unnecesary C- section ?

Difficulties for the analysis ü Which is the optimun cesarean rate? ü Many stategies Difficulties for the analysis ü Which is the optimun cesarean rate? ü Many stategies to reduce the rates Vaginal Birth = Quality Caserean Section = Clasical indicaton or failure Is there a different view ? Unnecesary C- section ?

Who are involved ? FETUS MOTHER Childbirth Unnecesary C- section ? Who are involved ? FETUS MOTHER Childbirth Unnecesary C- section ?

Who are involved ? FETUS Obstetricians MOTHER Childbirth Obstetrical Uni-Hospital Midwives Society Unnecesary C- Who are involved ? FETUS Obstetricians MOTHER Childbirth Obstetrical Uni-Hospital Midwives Society Unnecesary C- section ? Health system

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

“Unexplained fetal deaths” Cotzias C, Paterson Brown S, Fisk N. BMJ, 319, 31 july “Unexplained fetal deaths” Cotzias C, Paterson Brown S, Fisk N. BMJ, 319, 31 july 1999 Unnecesary C- section ?

Could C S reduce fetal death rate? ü ü ü 5 times more frequent Could C S reduce fetal death rate? ü ü ü 5 times more frequent than SIDS Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 Most of fetal deaths occur in non malformed fetuses Cotzias C, et al. , BMJ, 319, 31 july 1999 Unnecesary C- section ?

Could C S reduce fetal death rate? ü ü 5 times more frequent than Could C S reduce fetal death rate? ü ü 5 times more frequent than SIDS Termination of pregnancy when fetal risks in útero are larger than the risks of the newborn: 1/500 Most of fetal deaths occur in non malformed fetuses Women’s preference: C section of the risk is > 1: 4000 1 Cotzias C, et al. , BMJ, 319, 31 july 1999 1 Unnecesary C- section ? Thornton E, et al. , J Obstet Gynecol 1989; 9: 283 8

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

“Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury” Towner D “Effect of Mode of Delivery in Nulliparous Women on Neonatal Intracranial Injury” Towner D et al. , NEJM 1999; 341: 23 ü 1: 664 forceps ü 1: 860 vacuum extraction ü 1: 907 c section during labor ü 1: 1900 delivered spontaneously ü 1: 2750 c section with no labor Conclusion: The common risk factor for hemorrhage is abnormal labor Unnecesary C- section ?

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001 Frequency of cesarean section, primary cesarean and vaginal birth post-c-section between 1989 - 2001 VBAC All c-sections Primary c-section Martin JA, et al. , National Center for Health Statistics. 2002 Unnecesary C- section ?

Recomendations ü The most conservative recomendations. • ACOG Technical Bulletin. Vaginal delivery after a Recomendations ü The most conservative recomendations. • ACOG Technical Bulletin. Vaginal delivery after a previous cesarean birth. • • Int J Gynecol Obstet 48: 127 – 129; 1995. ACOG Vaginal birth after a previous cesarean. • ACOG Practice Bulletin N° 5: 1 – 8; 1999. Unnecesary C- section ?

VBAC ü Over 1000 reports: not one RCT Unnecesary C- section ? VBAC ü Over 1000 reports: not one RCT Unnecesary C- section ?

VBAC ü Over 1000 reports: not one RCT ü Economic forces rather than patient VBAC ü Over 1000 reports: not one RCT ü Economic forces rather than patient well being, are driving the goal of fewer cesarean sections ? 1 1 Clark Unnecesary C- section ? S. , et al. , Am J Obstet Gynecol 2000; 182: 599 602

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

Costs of deliveries ü Cesarean delivery: • • Longer hospital stay • ü Costs Costs of deliveries ü Cesarean delivery: • • Longer hospital stay • ü Costs more than a vaginal delivery Use of an operating room. Labor unit: a prolonged and difficult labor, even when it results in a vaginal delivery, is more costly to an institution than a cesarean delivery. Unnecesary C- section ?

Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA ü Elective repeated cesarean Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA ü Elective repeated cesarean delivery $ 7. 700 ü Normal vaginal delivery ü Intrapartum Cesarean: Unnecesary C- section ? $ 6. 800 $ 10. 000

Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA ü Elective repeated cesarean Costs of deliveries Beth Israel Deaconess Medical Center, Boston, USA ü Elective repeated cesarean delivery $ 7. 700 ü Normal vaginal delivery ü Intrapartum Cesarean: ü Complication • Mother: + $ 4. 000 • Child: + $ 2. 000 Unnecesary C- section ? $ 6. 800 $ 10. 000

Difficulties in the estimation of costs ü Poor quality: what resources were included in Difficulties in the estimation of costs ü Poor quality: what resources were included in their cost estimate ü Lack of progress of labor > more hospital lenght > medical costs > nursing costs ü Charges are not the same as costs ü Long term sequelae: Pelvic floor Fetal mortality Newborn trauma Unnecesary C- section ? Malkin J, et al. , Birth 2001; 28: 208 9

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

Pelvic floor ü Urinary incontinence ü Fecal incontinence ü Sexual dysfunction ü Organ prolapse Pelvic floor ü Urinary incontinence ü Fecal incontinence ü Sexual dysfunction ü Organ prolapse Unnecesary C- section ?

Pelvic floor ü Pudendal nerve damage ü Soft tissue trauma ü The levator musculature Pelvic floor ü Pudendal nerve damage ü Soft tissue trauma ü The levator musculature trauma ü Anal sphincter trauma Unnecesary C- section ?

Pelvic floor ü Pudendal nerve damage ü Soft tissue trauma ü The levator musculature Pelvic floor ü Pudendal nerve damage ü Soft tissue trauma ü The levator musculature trauma ü Anal sphincter trauma “. . . neurophysiologic studies have demonstrated the etiologic role of parturition-related nerve damage in development of pelvic floor disfunction. . . ” 1 1 Unnecesary C- section ? Davila GW, et al. , Int Urogyneocl J 2001; 12: 289 291

Reduction of pelvic floor damage ü Minimizing forceps deliveries ü Minimizing episiotomies ü Allowing Reduction of pelvic floor damage ü Minimizing forceps deliveries ü Minimizing episiotomies ü Allowing passive descent in the second stage ü Selectively recomending elective cesarean delivery Davila GW, et al. , Int Urogyneocl J 2001; 12: 289 291 Unnecesary C- section ?

Prevention of pelvic floor damage ü Avoid labor ü Avoid passage of the fetus Prevention of pelvic floor damage ü Avoid labor ü Avoid passage of the fetus through the pelvis ü Shorten second stage ü Avoid routine episiotomy ü Forget the forceps specially in macrosomia ü Repair perineal damage Devine II, Contemporary Ob/Gyn 1999: 119 Unnecesary C- section ?

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

Risk of maternal death “. . . the presumed increased risk of maternal death Risk of maternal death “. . . the presumed increased risk of maternal death with elective cesarean delivery traditionally has been the most compelling reason to reject a policy of universal cesarean delivery or "cesarean on demand. " However, good evidence is accumulating that this is no longer true; the maternal morbidity and mortality from elective cesarean delivery at term before the onset of labor appear to be similar to those associated with vaginal birth. . ” Unnecesary C- section ? Hannah ME, Lancet 2000; 356: 1375 83.

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

Cultural phenomena Brazil ü ü ü All birth are attended by obstetricians Training Doctors Cultural phenomena Brazil ü ü ü All birth are attended by obstetricians Training Doctors work in the public and private health system Status of c section: modern and technical Women’s body are perceived as sexual than maternal Genitals are perceived for sexual activity than for childbearing Nuttall C. , et al. , BMJ 2000; 320: 1072 Unnecesary C- section ?

Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC Factors involved in decision 1. Fetal mortality and morbidity 2. Newborn health 3. VBAC 4. Cost 5. Pelvic floor damage 6. Maternal mortality 7. Cultural factors 8. Autonomy C section on demand? Unnecesary C- section ?

Cesarean section on demand ü 31% of female obstetricians would prefer a cesarean delivery Cesarean section on demand ü 31% of female obstetricians would prefer a cesarean delivery for themselves 1 1 Unnecesary C- section ? Al Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997: 73: 1 4

Cesarean section on demand ü 31% of female obstetricians would prefer a cesarean delivery Cesarean section on demand ü 31% of female obstetricians would prefer a cesarean delivery for themselves 1 ü Italian law mandates that women be given the option of an elective cesarean, and about 4% of pregnant women choose it. 2 1 2 Unnecesary C- section ? Al Muffti et al. Eur J Obstet Gynecol Reprod Biol 1997: 73: 1 4 Tranquilli AL, et al. , Am J Obstet Gynecol 1997; 177: 245 246

Autonomy ü Is the governing principle in medicine ü We respect with better eyes Autonomy ü Is the governing principle in medicine ü We respect with better eyes a woman’s right to refuse a cesarean delivery ü Nobody is interested in respecting woman’s desire to refuse vaginal delivery Wagner M et al. , Lancet 2000; 356: 1677 80 Unnecesary C- section ?

Autonomy and informed consent ü Full and umbiased information (better=efficacy and worse=risks) ü Do Autonomy and informed consent ü Full and umbiased information (better=efficacy and worse=risks) ü Do we have the time to inform ? ü Male dominated obstetric model ü Does a woman have an inalienable “right” to choose a C S ? Wagner M et al. , Lancet 2000; 356: 1677 80 Unnecesary C- section ?

Autonomy and informed consent “. . . performing cesarean section for non medical reasons Autonomy and informed consent “. . . performing cesarean section for non medical reasons is ethically not justified. . ” Committee for the Ethical Aspects of Human Reproduction and Women’s Health of FIGO (1999) Unnecesary C- section ?

Ambiguity of terms ü Natural as desirable ü Natural as hazardous ü C section Ambiguity of terms ü Natural as desirable ü Natural as hazardous ü C section as safe ü C section as beneficial for doctors Unnecesary C- section ?

Natural (phylosophy of terms) ü To approve or excuse a behavior. Unnatural ü Ecologist’s Natural (phylosophy of terms) ü To approve or excuse a behavior. Unnatural ü Ecologist’s feeling against the danger of the nature ü Natural is everything that belong to the Universe (animate or liveless, rational o irrational) (Stuart Mill) ü Dynamic and historical concept Unnecesary C- section ?

Artificial (phylosophy of terms) ü What is produced by the arts and human technics Artificial (phylosophy of terms) ü What is produced by the arts and human technics ü Learned, modified. Natural is biologic. ü Natural in humans is not to be as much. (Savater) ü Artificial is better than natural. Which is the meaning of arts? (Savater) ü Human Life is precisely to be different from nature Unnecesary C- section ?

What do we need 1. RCT: intention of labor vs elective c section 2. What do we need 1. RCT: intention of labor vs elective c section 2. To accept that is a cultural phenomena 3. Need of a medical and non medical approach 4. Informed Consent Unnecesary C- section ?

To think A change in the birth of human specie has been produced in To think A change in the birth of human specie has been produced in the last years The same happened in terms of fertilization. It is not mediated by a natural evolution, Darwinian, but by an artificial evolution of human being. This controversy must not be solved replacing vaginal birth with c section, but stimulating women’s informed consent regarding the aspects of birth. Unnecesary C- section ?

To think ü The nature of birth is related with the female’s function as To think ü The nature of birth is related with the female’s function as a reproductive agent. Is the same for the women’s condition? ü 9 month not natural and then a natural birth ü Have we done a damage? ü You can do. . but , should you do it? ü Women’s selection for vaginal birth Unnecesary C- section ?

Conclusion “. . . perhaps the time has come when the risks, benefits and Conclusion “. . . perhaps the time has come when the risks, benefits and costs are so balanced between cesarean section and vaginal delivery that the deciding factor should simply be the mother’s preference for how her baby is to be delivered. . . ” William Benson Harer Unnecesary C- section ?

Conclusion The cesarean section should not be used as an indicator of quality of Conclusion The cesarean section should not be used as an indicator of quality of obstetrical care We do not have a good definition of unnecesary c section Unnecesary C- section ?

Thank you. -Dr. Mario Sebastiani. Asociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Thank you. -Dr. Mario Sebastiani. Asociación Argentina de Ginecología y Obstetricia Psicosomática Servicio de Obstetricia. Hospital Italiano de Buenos Aires. Argentina